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Biomedical subjects

C Fleming

Publications and source records attributed to C Fleming.

At least 55 records · Page 3Linked to original sources
PubMed1996

Quality improvement of diagnostic microbiology through a peer-group proficiency assessment program. A 20-year experience in Ontario. The Microbiology Committee.

OBJECTIVE: To evaluate the microbiology laboratory performance in Ontario over a 20-year period of participation in a quality assessment program and to assess the impact of quality improvement strategies. DESIGN: Longitudinal review of isolation, identification, and antimicrobial susceptibility testing of bacteria from lyophilized, simulated patient samples. SETTING: Ontario medical laboratories, licensed by the Ministry of Health, have been subjected to mandatory testing by the Laboratory Proficiency Testing Program of the Ontario Medical Association since 1974. Survey reports, information bulletins, correspondence, on-site consultations, educational assistance tutorials, and teleconference education are used as quality improvement strategies. PARTICIPANTS AND INTERVENTIONS: Laboratories were subjected annually to 20 external quality assessment challenges. Performance was assessed against consensus reference values. Single survey and cumulative profiles were reviewed by a peer-group panel for acceptable or unacceptable performance. Specific interventions are used to improve collective and individual laboratory performance. RESULTS: The number of microbiology laboratories declined from 335 in 1974 to 190 in 1994. Twenty-one percent failed expected performance standards on initial review. One hundred forty-two on-site consultations and 61 educational assistance tutorials have been provided. Twenty-five laboratories were declared nonproficient. Since 1989, 50% of the laboratories have scored at or above 80% for isolation and identification, but 25% have scored at or below 50% on susceptibility testing, and 10% or fewer have scored at or above 80%. Poor susceptibility testing performance is due to inappropriate agent selection, not testing errors. CONCLUSIONS: The emphasis of the Laboratory Proficiency Testing Program is on quality improvement, not punishment. Performance has improved, but poor performers have the same characteristics as in 1974. Identification to species is common owing to the use of commercial systems. Automated susceptibility testing has increased to 45% of participants.

Bacterial Infections↗
PubMed1995

Frequency of diabetes in family members of probands with non-insulin-dependent diabetes mellitus.

OBJECTIVES: To describe the prevalence of known diabetes in a multi-ethnic community in South Auckland, New Zealand, in relation to family history of diabetes and past history of diabetes in pregnancy. DESIGN: A cross-sectional, household survey comparing ascertainment with local general practice diabetes registers where they existed. SETTING: An inner-city community with a high proportion of Maori, Pacific Islands people and Europeans. SUBJECTS: A total of 55,518 residents (91% response). Comparison with diabetes registers showed 91% ascertainment of known diabetic residents. More detailed interviews with 176/214 (82%) Europeans, 286/336 (85%) Maori and 495/585 (85%) Pacific Islands people with known diabetes. Fifty subjects had insulin-dependent diabetes mellitus on clinical criteria and were excluded from analyses. MAIN OUTCOME MEASURES: Prevalence of diabetes. RESULTS: Those with non-insulin-dependent diabetes mellitus were more likely to have a diabetic mother than father (Europeans, 21.7% vs. 9.9%; Maori, 17.6 vs. 11.4%; Pacific Islands, 15.7 vs. 5.3%). Diabetic women had a similar likelihood of having a diabetic father as diabetic men but were 1.84 times as likely to have a diabetic mother (95% CI, 1.27-2.69). Diabetic women with past diabetes in pregnancy had 2.05 (95% CI, 1.01-4.15) times the chance of a diabetic offspring as women who had not had past diabetes in pregnancy, who in turn had 2.69 (95% CI, 1.17-6.18) times the likelihood of having a diabetic offspring as diabetic men. CONCLUSIONS: The mother is a more important conduit for inheritance of diabetes than the father in these three ethnic groups. A history of diabetes in pregnancy confers an extra risk to the offspring above this usual maternal excess.

Adolescent↗
PubMed1995

Ethnic differences in the perception of a video developed for a multiethnic diabetes prevention programme in south Auckland, New Zealand.

Videos were developed to help increase diabetes awareness among local Maori, Pacific Islands and European communities. The Maori and Pacific Islands versions incorporated modifications to the basic content to make them more appropriate for the target audience. Lay audiences, comprising 108 Europeans, 94 Maori and 90 Pacific Islands people in 12 different sites, viewed the version of the video tailored to their ethnic group. The Maori version was also viewed by 32 Diabetes Nurse Specialists. Likert scale ratings and open-ended questions were used to evaluate the video. The video was rated highly by all audiences and most subjects were able to repeat the main messages of the video. Compared with Maori and Pacific Islands subjects, Europeans found the video the easiest to understand but gained the least information. Maori and Pacific Islands subjects would have preferred a longer video ( > 17 minutes). Different viewing sites revealed evidence of within-ethnic-group heterogeneity. Pacific Islands subjects particularly appreciated the educational components, while Maori and Europeans were more likely to comment on presentation. Audio-visual material is perceived differently by different ethnic groups, such differences need to be addressed when embarking on diabetes awareness campaigns.

Adult↗
PubMed1995

How to determine decisional capacity in critically ill patients. Presume the patient can make decisions unless proven otherwise.

Decisional capacity includes ability to comprehend information, to make an informed choice, and to communicate that choice; it is specific to the decision at hand. Presume a patient has decisional capacity; an evaluation of incapacity must be justified. Administer a standardized mental status test to help assess alertness, attention, memory, and reasoning ability. A patient scoring below 10 on the Folstein Mini-Mental State Examination (maximum score, 30) probably does not have decisional capacity; one scoring from 10 to 15 probably can designate a proxy but not make complex health care decisions. Obtain psychiatric consultations for a patient who exhibits psychological barriers to decision making.

Amyotrophic Lateral Sclerosis↗
PubMed1995

Using advance directives effectively in the intensive care unit. Terminating care in the presence--or absence--of directives.

When a patient is admitted to the ICU, determine whether the person has decisional capacity and whether an advance directive exists. If so, discuss treatment options and the directive with the patient--as well as with family members and appointed surrogates; clarify the patient's wishes. If no directive has been drawn up, encourage the patient to do so. If a patient lacks decisional capacity but has a directive, determine whether it applies to the current situation. If it does, follow its instructions. If no directive exists or if it does not apply, consult with family members to determine the patient's wishes, and ascertain whether these substitute judgments meet state laws.

Advance Directives↗
PubMed1995

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts.

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.

Cardiopulmonary Resuscitation↗
PubMed1995

Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit.

Inappropriate benzodiazepine dosing in patients exhibiting signs of alcohol withdrawal cause staff and patient safety problems. Our primary goal was to develop an alcohol withdrawal protocol based on objective measures, and then to coordinate benzodiazepine dosing with those measures and improve care of the patient withdrawing from alcohol. A secondary goal was to give the primary care nurse the flexibility to administer benzodiazepine doses as needed to improve patient and staff safety. We developed and implemented a modified version of a published withdrawal symptomatology scale; a corresponding scale was developed for benzodiazepine dosing by observing the usual lorazepam doses needed to control withdrawal symptoms. Both scales and care guidelines for the patient withdrawing from alcohol were organized in the form of preprinted orders. Since implementation of the alcohol withdrawal protocol, complaints regarding patient and staff safety have decreased. Other patient care units are beginning to use the protocol. A hospital-wide task force is developing patient care plans based on the protocol for all patients withdrawing from alcohol.

Alcohol Withdrawal Delirium↗
PubMed1994

Prevalence of known diabetes in a multiethnic community.

AIMS: To describe the prevalence of known diabetes in an area of New Zealand with a large Pacific Islands and Maori population. METHOD: A cross sectional door to door census with identification of those with known diabetes was conducted between April and October 1992. The data was validated by comparison with available local general practice diabetes registers and data from a repeat visit to a randomly selected 5% of houses. RESULTS: Interviews were completed at 92.7% of the 5081 households, containing 22,651 residents (1417 European, 5606 Maori, 14,802 Pacific Islands). The Pacific Islands population was 40% larger than that predicted from the 1991 census. The age adjusted prevalence of known diabetes in adults (aged > or = 20 years) was 2.8% (95% CI 1.9-3.9) in Europeans, 6.9% (95% CI 6.0-7.9) in Maori and 4.6% (95% CI 4.1-5.1) in Pacific Islands people. The greatest differences in prevalence were found in those aged 40-59 years. Interviews at 185/280 houses revisited showed that 13% of households had moved completely in the 2-8 months between visits. Comparison between participating general practice registers and the door to door survey database showed that 11.2% (26/232) of diabetic individuals were missed by the door to door survey, and 23.7% (55/232) were not on the register of the named general practitioner. CONCLUSIONS: The prevalence of known diabetes in the community is much higher than that in the workforce. Differences between Maori and Pacific Islands people may be due to more undiagnosed diabetes or a lower risk of diabetes in the latter.

Adolescent↗
PubMed1994

Self-help for bulimia nervosa: a preliminary report.

Eighteen patients with DSM-III-R bulimia nervosa were treated by providing them with supervision in the use of a self-help manual based on the cognitive behavioral treatment for the disorder. The patients were assessed before beginning the self-help program, and again 4 to 6 months later, using standardized measures of psychopathology. The findings were encouraging. At follow-up one half of the patients had ceased bulimic episodes and self-induced vomiting, and most of the remainder had made significant improvements. These preliminary findings, together with related published work, suggest that supervised self-help might be an appropriate first line treatment for patients with bulimia nervosa and that for many patients it could be sufficient.

Behavior Therapy↗
PubMed1994

Correlation of polymorphic expression of CYP2D6 mRNA in bladder mucosa and tumor tissue to in vivo debrisoquine hydroxylase activity.

Debrisoquine hydroxylase activity has been attributed to CYP2D6 and poor metabolizers of debrisoquine have a reduced relative risk of developing aggressive bladder cancer. Production of a proximate carcinogen could occur in liver or bladder mucosa. However, it is not known if CYP2D6 is expressed in human bladder mucosa. In vivo whole body debrisoquine hydroxylase activity was measured as the debrisoquine recovery ratio (DBRR) following single dose oral administration of debrisoquine (10 mg) in 10 normal subjects and 20 patients with bladder cancer prior to diagnostic cystoscopy. Semi-quantitative PCR was used to measure mRNA for CYP2D6 in bladder tissue obtained at cystoscopy. Of the 30 subjects, three were phenotypically and genotypically poor metabolizers. Among the extensive metabolizers, there were extensive intersubject variations in DBRR. A 10-fold variation in CYP2D6 mRNA levels was observed in bladder tissue. There was a highly significant association between DBRR and CYP2D6 mRNA expression (r2 = 0.702, P < 0.001). These results demonstrate the presence of CYP2D6 mRNA in bladder mucosa. Furthermore, they are consistent with debrisoquine hydroxylation being mediated by CYP2D6 and suggest that differences in mRNA concentration are rate limiting for enzyme activity and that bladder mucosal regulation reflects total body regulation for this enzyme. The expression of CYP2D6 in bladder mucosa suggests that this enzyme could be involved in the local production of a proximate carcinogen in this tissue and contribute to the pathogenesis of bladder cancer in man.

Base Sequence↗
PubMed1994

Apparent lack of seasonal variation in implantation rates after in-vitro fertilization.

It has been suggested that seasonal variation in endometrial receptivity may occur in women, which could affect the likely success of in-vitro fertilization (IVF) treatment. We therefore studied implantation rates (fetal sacs as a proportion of embryos transferred) as an indirect index of receptivity in a narrowly defined population of women under 40 years old with normal ovulatory cycles and normal uterus and men with normal sperm function. A total of 577 cycles of IVF treatment were undertaken using a standard protocol of pituitary desensitization and ovarian stimulation during the 3 years 1990-1992. Results were compared between calendar months and 3-month seasons. The overall implantation rate was 14.9% of embryos, and the clinical pregnancy rate was 30.3% of cycles reaching egg collection. There were no significant differences in the monthly rates of eggs collected, fertilization and cleavage, or embryos transferred. Implantation rates varied to a greater extent but analysis of variance showed no seasonal variation. These findings do not support a seasonal variation in ovarian responsiveness or endometrial receptivity when stimulated for IVF treatment, but larger studies are needed for firm conclusions to be drawn.

Adult↗
PubMed1994

Increasing melanoma incidence: putatively explainable by retrotransposons. Experimental contributions of the xiphophorine Gordon-Kosswig melanoma system.

The worldwide accelerating increase of neoplasia in humans is difficult to explain. We use the Xiphophorus tumor model to approach this problem by melanoma provocation with X-rays. Melanoma develops following inappropriate expression of x-erb B-conducted developmental genes and their controllers. These oncodeterminants are inherited according to Mendelian rules. We detected a new type of oncodeterminants that, following a single treatment of embryos with X-rays, generates a self-generating non-Mendelian melanoma transmission and accelerating increase of its incidence in succeeding generations (e.g., 0-->18-->33-->52%). To localize these oncodeterminants, we crossed nonirradiated fish having half of their chromosomes irradiated with nonirradiated fish having none of, half of, or all of their chromosomes irradiated. Because tumor rate and expression in the following generations correspond to the rates of treated chromosomes, we conclude that the new oncodeterminants are distributed over the chromosomes of the fish, where they may increase in the changing generations. By means of xiphophorine-specific retroviral DNA, we isolated two retrotransposons that behave hereditarily like the new transgenerational oncodeterminants. Sequence analysis revealed three ORFs flanked by LTRs containing motives of regulatory sequences typical for known retroviral and retrotransposal LTRs. Pol- and env-resembling sequences are lacking. Southern and in situ hybridization showed their multiple and repetitive nature distributed throughout the chromosomes and indications for their capability to increase in number without further treatment. Their transcripts are expressed in concert with those of most of the other known xiphophorine tumor determinants. Their expression is extremely high in cell cultures from tumorous embryos derived from ancestors treated as embryos with X-rays.

Animals↗
PubMed1994

Expression of dihydropyridine resistance differs in porcine bronchial and tracheal smooth muscle.

Voltage-dependent and receptor-operated Ca2+ entry mechanisms have been demonstrated in airway smooth muscle, but their relative importance for maintenance of contraction is unknown. Blockade of voltage-dependent Ca2+ channels (VDC) has produced inconsistent relaxation. We postulated regional variations in Ca2+ handling by airway smooth muscle cells and compared the efficacy of dihydropyridine VDC blockers in tracheas and bronchi. Porcine tracheal smooth muscle strips and bronchial rings were mounted in tissue baths filled with physiological solutions and isometric tension was measured. Tissues were precontracted with carbachol or KCl, and relaxation dose-response curves to nifedipine, Mn2+, or Cd2+ were obtained. Relaxation responses to nifedipine were significantly different in carbachol-contracted tracheas and bronchi. Whereas carbachol-contracted tracheal muscle completely relaxed with 10(-6) M nifedipine, bronchial smooth muscle relaxed < 50%. In contrast, KCl-contracted bronchial muscle was completely relaxed by nifedipine. The nonspecific Ca2+ channel blockers Mn2+ and Cd2+ produced similar relaxation responses in each tissue. Thus VDC are the predominant mechanism for Ca2+ entry in porcine tracheal smooth muscle, but a dihydropyridine-insensitive pathway is functionally important in carbachol-contracted porcine bronchi. Regional variation may account for apparent inconsistencies between previous studies.

Animals↗